National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (14)
- Adverse Events (36)
- Ambulatory Care and Surgery (1)
- Blood Pressure (1)
- Cancer (1)
- Cardiovascular Conditions (1)
- Care Coordination (1)
- Children/Adolescents (5)
- Clinical Decision Support (CDS) (4)
- Clinician-Patient Communication (3)
- Communication (4)
- Comparative Effectiveness (2)
- Critical Care (2)
- Data (1)
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- Diagnostic Safety and Quality (14)
- Electronic Health Records (EHRs) (9)
- Emergency Department (3)
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- Healthcare Costs (2)
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- Health Information Technology (HIT) (19)
- Health Services Research (HSR) (1)
- Hospital Discharge (1)
- Hospitals (2)
- Imaging (1)
- Inpatient Care (3)
- Intensive Care Unit (ICU) (1)
- Labor and Delivery (2)
- Long-Term Care (1)
- (-) Medical Errors (60)
- Medical Liability (4)
- Medicare (1)
- Medication (17)
- Medication: Safety (8)
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- Nursing Homes (1)
- Opioids (1)
- Patient and Family Engagement (1)
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- Transitions of Care (1)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 60 Research Studies DisplayedKhan A, Spector ND, Baird JD
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
The objective of this prospective, multicenter before and after intervention was to determine whether medical errors, family experience, and communication processes improved after implementation of the intervention to standardize the structure of healthcare provider-family communication on family centered rounds. The investigators concluded that although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved.
AHRQ-funded; HS00063.
Citation: Khan A, Spector ND, Baird JD .
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
BMJ 2018 Dec 5;363:k4764. doi: 10.1136/bmj.k4764..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Medical Errors, Patient and Family Engagement, Patient Safety
Medford-Davis LN, Singh H, Mahajan P
Diagnostic decision-making in the emergency department.
Emergency providers must often diagnose from undifferentiated symptoms, without previous knowledge of the patient. Failure to provide an accurate assessment of the problem or to communicate the problem to the patient is diagnostic error. This article considers methods to monitor diagnostic error in emergency departments.
AHRQ-funded; HS024953.
Citation: Medford-Davis LN, Singh H, Mahajan P .
Diagnostic decision-making in the emergency department.
Pediatr Clin North Am 2018 Dec;65(6):1097-105. doi: 10.1016/j.pcl.2018.07.003..
Keywords: Emergency Department, Diagnostic Safety and Quality, Decision Making, Medical Errors, Patient Safety
Wright A, Aaron S, Seger DL
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
This study examined the effects of conversion from a homegrown electronic health record (EHR) system to a commercial system on the effectiveness of drug-drug interaction (DDI) alert. The EHR system included 3277 clinicians in the before and after studies. There was a marked decrease in the acceptance rate (100 to 8.4% for severe alerts, 29.3 to 7.5% for medium severity) at first. The least severe alerts were then disabled, which lowered the alert burden by 50.5% which rose the acceptance of Tier 1 alerts to 12.7%. However, there was no clear explanation after that why the acceptance rate remained so much lower. The authors believe that workflow factors were probably the predominant reasons.
AHRQ-funded; HS016970.
Citation: Wright A, Aaron S, Seger DL .
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
J Gen Intern Med 2018 Nov;33(11):1868-76. doi: 10.1007/s11606-018-4415-9..
Keywords: Adverse Drug Events (ADE), Medication, Adverse Events, Medical Errors, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Schiff G, Mirica MM, Dhavle AA
A prescription for enhancing electronic prescribing safety.
The authors review six areas in which electronic prescribing areas can be improved to transform medication ordering quality and safety. They recommend incorporating medication indications into electronic prescribing, establishing a single shared online medication list, implementing an electronic cancellation mechanism for pharmacies, implementing standardized structured and codified prescription instruction, reengineering clinical decision support, and redesigning electronic prescribing to facilitate ordering of nondrug alternatives.
AHRQ-funded; HS023694.
Citation: Schiff G, Mirica MM, Dhavle AA .
A prescription for enhancing electronic prescribing safety.
Health Aff 2018 Nov;37(11):1877-83. doi: 10.1377/hlthaff.2018.0725..
Keywords: Adverse Drug Events (ADE), Adverse Events, Health Information Technology (HIT), Healthcare Delivery, Medical Errors, Medication, Medication: Safety, Patient Safety
Cochon L, Lacson R, Wang A
Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.
The purpose of this study was to assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. Information sources can elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.
AHRQ-funded; HS024722.
Citation: Cochon L, Lacson R, Wang A .
Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.
J Am Med Inform Assoc 2018 Nov;25(11):1507-15. doi: 10.1093/jamia/ocy103..
Keywords: Diagnostic Safety and Quality, Imaging, Medical Errors, Patient Safety
Ratwani RM, Savage E, Will A
Identifying electronic health record usability and safety challenges in pediatric settings.
To understand specific usability issues and medication errors in the care of children, the investigators analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. They found: the general pattern of usability challenges and medication errors were the same across the three sites; the most common usability challenges were associated with system feedback and the visual display; and the most common medication error was improper dosing.
AHRQ-funded; HS023701.
Citation: Ratwani RM, Savage E, Will A .
Identifying electronic health record usability and safety challenges in pediatric settings.
Health Aff 2018 Nov;37(11):1752-59. doi: 10.1377/hlthaff.2018.0699..
Keywords: Children/Adolescents, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Children/Adolescents
Berenson R, Singh H
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
Researchers examined ways that payment innovations could be used to improve diagnostic accuracy and reduce diagnostic error among Medicare patients. They recommended three different approaches: 1) coding changes in the Medicare Physician Fee schedule; new Alternative Payment Models (APMs) that could improve accuracy in challenging cases and even provide second or third opinions; and 3) have a method that accurate diagnoses would trigger APM payments and establish payment amounts.
AHRQ-funded; HS022087; HS017820.
Citation: Berenson R, Singh H .
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
Health Aff 2018 Nov;37(11):1828-35. doi: 10.1377/hlthaff.2018.0714..
Keywords: Diagnostic Safety and Quality, Payment, Medical Errors, Medicare, Patient Safety, Quality of Care
Bates DW, Singh H
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
This paper comments on the progress made in improving patient safety since the 1999 report from The Institute of Medicine titled “To Err is Human” was published. This landmark report highlighted problem areas, and since then there has been a number of effective interventions to prevent hospital-acquired infections and improve medication safety. Additional areas for improvement have also been identified in the past two decades, including outpatient care, diagnostic, errors and the use of health information technology. The authors believe that electronic data developments can help increase patient safety even further.
AHRQ-funded; HS022087; HS017820.
Citation: Bates DW, Singh H .
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Health Aff 2018 Nov;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738..
Keywords: Adverse Drug Events (ADE), Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Prevention
Gupta A, Harrod M, Quinn M
Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.
This study focused on how system problems within two academic institutions contribute to cognitive and diagnostic errors of inpatient physicians. Observations were conducted by physicians, nurses, and non-clinicians (qualitative researchers, social scientists and health care engineers). Focus groups were also conducted. System-based problems included interruptions, time constraints and physical space.
AHRQ-funded; HS024385; HS022835; HS022087.
Citation: Gupta A, Harrod M, Quinn M .
Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.
Diagnosis 2018 Sep 25;5(3):151-56. doi: 10.1515/dx-2018-0014..
Keywords: Diagnostic Safety and Quality, Quality of Care, Healthcare Delivery, Inpatient Care, Medical Errors
Slight SP, Seger DL, Franz C
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
Investigators worked to determine the national cost of adverse drug events (ADEs) in the United States in 2014. They used three different regression models. They used a random sample of 40,990 adult inpatients at the Brigham and Women’s Hospital in Boston with over 1.6 million medication orders. They extrapolated the medication orders using 2014 National Inpatient Sample (NIS) data. They estimated that out of 78.8 million total medication alerts, 5.5 million medication alerts would have been inappropriately overridden resulting in 196,660 ADEs. They estimated it would have cost between $871 million and $1.8 billion for treating these preventable ADEs in the United States.
AHRQ-funded; HS021094.
Citation: Slight SP, Seger DL, Franz C .
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
J Am Med Inform Assoc 2018 Sep;25(9):1183-88. doi: 10.1093/jamia/ocy066..
Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT), Healthcare Costs, Medical Errors, Medication
Bergl PA, Nanchal RS, Singh H
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Despite progress in ICU safety, diagnostic errors remain largely unexplored and under-studied in critical care. Compared to other safety problems, diagnostic errors are more difficult to identify and, due to the intricacies of the diagnostic process, are more difficult to unravel. This paper discusses diagnostic error in critically ill patients, defines the problem and explores next steps to advance ICU safety.
AHRQ-funded; HS022087.
Citation: Bergl PA, Nanchal RS, Singh H .
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Ann Am Thorac Soc 2018 Aug;15(8):903-07. doi: 10.1513/AnnalsATS.201801-068PS..
Keywords: Adverse Events, Critical Care, Diagnostic Safety and Quality, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Stockwell DC, Landrigan CP, Toomey SL
Adverse events in hospitalized pediatric patients.
Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). This study used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. The study concluded that AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.
AHRQ-funded; HS020513
Citation: Stockwell DC, Landrigan CP, Toomey SL .
Adverse events in hospitalized pediatric patients.
Pediatrics 2018 Aug;142(2). doi: 10.1542/peds.2017-3360..
Keywords: Children/Adolescents, Adverse Events, Patient Safety, Inpatient Care, Medical Errors
Zhou L, Blackley SV, Kowalski L
Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.
The purpose of this study was to identify and analyze errors at each stage of the speech recognition (SR) assisted dictation process. The study concluded that seven in 100 words in SR-generated documents contain errors; many errors involve clinical information. That most errors were corrected before notes were signed demonstrates the importance of manual review, quality assurance, and auditing.
AHRQ-funded; HS024264.
Citation: Zhou L, Blackley SV, Kowalski L .
Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.
JAMA Network Open 2018 Jul;1(3):e180530. doi: 10.1001/jamanetworkopen.2018.1627..
Keywords: Quality of Care, Health Information Technology (HIT), Health Services Research (HSR), Medical Errors, Patient Safety
Bell SK, Etchegaray JM, Gaufberg E
A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.
A one-day conference of diverse stakeholder groups convened to establish a consensus-driven research agenda focused on the impact of patient and family emotional harm stemming from preventable medical error. Stakeholder groups reached consensus and designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.
AHRQ-funded; HS024463.
Citation: Bell SK, Etchegaray JM, Gaufberg E .
A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.
Jt Comm J Qual Patient Saf 2018 Jul;44(7):424-35. doi: 10.1016/j.jcjq.2018.03.007..
Keywords: Adverse Events, Medical Errors, Patient Safety, Research Methodologies
Olson AP, Graber ML, Singh H
Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.
The authors of this paper propose a new framework to identify “undesirable diagnostic events” (UDEs) to help establish reliable and valid measures for diagnostic errors. They proposed an outline for UDEs to identify conditions prone to diagnostic error and the contexts of care in which those errors are likely to occur.
AHRQ-funded; HS022087; HS023602.
Citation: Olson AP, Graber ML, Singh H .
Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.
J Gen Intern Med 2018 Jul;33(7):1187-91. doi: 10.1007/s11606-018-4304-2..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Rosenbluth G, Destino LA, Starmer AJ
I-PASS handoff program: use of a campaign to effect transformational change.
Successful implementation of the I-PASS handoff bundle with subsequent decreases in medical errors and preventable adverse events represents an example of successful transformational change within academic medical centers. The study authors designed a campaign to support and enhance uptake of the I-PASS handoff bundle at 9 study sites from 2011 to 2013.
AHRQ-funded; HS019456.
Citation: Rosenbluth G, Destino LA, Starmer AJ .
I-PASS handoff program: use of a campaign to effect transformational change.
Pediatr Qual Saf 2018 Jul-Aug;3(4):e088. doi: 10.1097/pq9.0000000000000088..
Keywords: Adverse Events, Medical Errors, Patient Safety
Wang J, Ali E, Gong Y
An information enhanced framework for reporting medication events.
In this article, the authors describe a proposed framework to discover supportive information from the FDA Adverse Event Reporting System (FAERS), an open data source, to enhance the reporting of insulin-use events. The framework represents a paradigm for developing an information enhanced electronic reporting system.
AHRQ-funded; HS022895.
Citation: Wang J, Ali E, Gong Y .
An information enhanced framework for reporting medication events.
Stud Health Technol Inform 2018;250:169-73..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Medication: Safety, Patient Safety
Kannampallil TG, Manning JD, Chestek DW
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
The authors examined the effect of number of open charts on intercepted wrong-patient medication orders in an emergency department using an interrupted time series analysis of intercepted wrong-patient medication orders in an emergency department during 2010-2016.
AHRQ-funded; HS024945.
Citation: Kannampallil TG, Manning JD, Chestek DW .
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
J Am Med Inform Assoc 2018 Jun;25(6):739-43. doi: 10.1093/jamia/ocx099..
Keywords: Adverse Drug Events (ADE), Emergency Department, Medical Errors, Medication, Medication: Safety, Patient Safety
Zhou S, Kang H, Yao B
Unveiling originated stages of medication errors: an automated pipeline approach.
Medication error reports collected by Patient Safety Organizations provide an opportunity to analyze and learn from previous cases. However, the current process of analyzing the reports is labor-intensive and time-consuming. To improve the efficiency, the investigators used automated text classification techniques to develop a pipeline for medication error report pre-analysis.
AHRQ-funded; HS022895.
Citation: Zhou S, Kang H, Yao B .
Unveiling originated stages of medication errors: an automated pipeline approach.
Stud Health Technol Inform 2018;250:182-86..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Medication: Safety, Patient Safety
Muldoon MF, Kronish IM, Shimbo D
Of signal and noise: overcoming challenges in blood pressure measurement to optimize hypertension care.
This paper reviews the manifestations and consequences of BP mismeasurement and misinterpretation in clinical practice and draw on recent research to propose a set of solutions that leverage available technologies to optimize hypertension care.
AHRQ-funded; HS024262.
Citation: Muldoon MF, Kronish IM, Shimbo D .
Of signal and noise: overcoming challenges in blood pressure measurement to optimize hypertension care.
Circ Cardiovasc Qual Outcomes 2018 May;11(5):e004543. doi: 10.1161/circoutcomes.117.004543..
Keywords: Blood Pressure, Diagnostic Safety and Quality, Adverse Events, Medical Errors, Electronic Health Records (EHRs), Health Information Technology (HIT), Quality of Care
Howe JL, Adams KT, Hettinger AZ
Electronic health record usability issues and potential contribution to patient harm.
Researchers analyzed reports of possible patient harm that explicitly mentioned a major EHR vendor or product. They concluded that EHR usability may have been a contributing factor to some possible patient harm events. Only a small percentage of potential harm events were associated with EHR usability, but the analysis was conservative because safety reports only capture a small fraction of the actual number of safety incidents.
AHRQ-funded; HS023701.
Citation: Howe JL, Adams KT, Hettinger AZ .
Electronic health record usability issues and potential contribution to patient harm.
JAMA 2018 Mar 27;319(12):1276-78. doi: 10.1001/jama.2018.1171.
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Keywords: Adverse Events, Electronic Health Records (EHRs), Medical Errors, Patient Safety, Risk
Dynan L, Goudie A, Brady PW
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
In this article, the investigators hypothesize that adverse event rates increase with the availability of more complex services and technologies (transplantation and pediatric open-heart surgery); increase as experience of providers decreases (July effect); and increase with residents per bed, a measure of both average provider inexperience and congestion. Using multilevel analysis, they found empirical evidence in support of their three hypotheses.
AHRQ-funded; HS023827.
Citation: Dynan L, Goudie A, Brady PW .
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
J Healthc Qual 2018 Mar/Apr;40(2):69-78. doi: 10.1097/jhq.0000000000000121..
Keywords: Children/Adolescents, Healthcare Cost and Utilization Project (HCUP), Adverse Events, Hospitals, Inpatient Care, Medical Errors, Patient Safety
Rinke ML, Singh H, Heo M
Diagnostic errors in primary care pediatrics: Project RedDE.
The objective of this study was to investigate the frequency of two high-frequency/subacute diagnostic errors (DEs), and one missed opportunity for diagnosis (MOD) in primary care pediatrics. DE or MOD rates in pediatric primary care were found to be 54 percent for patients with elevated BP, 11 percent for patients with abnormal laboratory values, and 62 percent for adolescents with an opportunity to evaluate for depression.
AHRQ-funded; HS022087; HS023608; HS023602.
Citation: Rinke ML, Singh H, Heo M .
Diagnostic errors in primary care pediatrics: Project RedDE.
Acad Pediatr 2018 Mar;18(2):220-27. doi: 10.1016/j.acap.2017.08.005.
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Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Primary Care, Quality Improvement
Larsen E, Fong A, Wernz C
Implications of electronic health record downtime: an analysis of patient safety event reports.
Researchers sought to understand the types of clinical processes, such as image and medication ordering, that are disrupted during electronic health record (EHR) downtime periods by analyzing the narratives of patient safety event report data. They concluded that patient safety report data offer a lens into EHR downtime-related safety hazards. Important areas of risk during EHR downtime periods were patient identification and communication of clinical information.
AHRQ-funded; HS024350.
Citation: Larsen E, Fong A, Wernz C .
Implications of electronic health record downtime: an analysis of patient safety event reports.
J Am Med Inform Assoc 2018 Feb;25(2):187-91. doi: 10.1093/jamia/ocx057.
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Keywords: Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Patient Safety
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care